Acta Oto-Laryngologica

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Hearing loss after bacterial meningitis, a

retrospective study

Filip Persson, Nora Bjar, Ann Hermansson & Marie Gisselsson-Solen

To cite this article: Filip Persson, Nora Bjar, Ann Hermansson & Marie Gisselsson-Solen (2022)
Hearing loss after bacterial meningitis, a retrospective study, Acta Oto-Laryngologica, 142:3-4,
298-301, DOI: 10.1080/00016489.2022.2058708

To link to this article: https://doi.org/10.1080/00016489.2022.2058708

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ACTA OTO-LARYNGOLOGICA
2022, VOL. 142, NOS. 3–4, 298–301
https://doi.org/10.1080/00016489.2022.2058708

RESEARCH ARTICLE

Hearing loss after bacterial meningitis, a retrospective study

Filip Perssona, Nora Bjarb, Ann Hermanssonb and Marie Gisselsson-Solenb
a
Lund University Hospital, Lund, Sweden; bDepartment of Otorhinolaryngology, Head and Neck Surgery, Skåne University Hospital,
Lund, Sweden

ABSTRACT ARTICLE HISTORY

Background: Hearing loss is a common sequela after bacterial meningitis, but risk factors for this are Received 15 February 2022
poorly studied, particularly in relation to concurrent acute otitis media (AOM). Revised 15 March 2022
Aims: The aim of this study was to investigate incidence and risk factors for hearing loss in patients Accepted 17 March 2022
treated for bacterial meningitis.
KEYWORDS
Methods: In this retrospective study, medical records for patients admitted to hospital with bacterial Acute otitis media; AOM;
meningitis in Skåne county, Sweden, between 2000 and 2017 were retrieved. The association between Streptococcus pneumoniae;
risk factors and hearing loss was estimated using logistic regression. bacterial meningitis; hearing
Results: During the 18 years, 187 cases of meningitis were identified. Hearing loss was confirmed in loss; risk factor
71 of the 119 patients who had done an audiometry. It was significantly more common in adults.
There was also evidence of an association between hearing loss and AOM, and between hearing loss
and pneumococcal infection.
Conclusion: Age, concurrent AOM and pneumococcal infection were risk factors for developing hear-
ing loss. Despite being recommended in the national guidelines, more than a third of the patients
had not done a hearing test after recovering from bacterial meningitis. The findings strengthen the
demand for prompt ear examination and – if needed – tympanocentesis in meningitis patients.

Introduction The aim of this study was to investigate the incidence of

Meningitis is a life-threatening infection which sometimes
occurs as a complication to acute otitis media (AOM). It is
not entirely known what percentage of bacterial meningitis
is of otogenic origin. A Dutch study found that the most
common agents causing community-acquired meningitis
was Streptococcus pneumoniae (53%), and Neisseria meningi-
tidis (37%), and that concurrent AOM was a risk factor for
negative outcome, indicating the importance of prompt ear
examination [1]. A French study of children with bacterial
meningitis also identified S. pneumoniae (39%) and N. men-
ingitidis (39%) as the most important pathogens [2].
The most common sequela after bacterial meningitis is
hearing loss [3,4]. This is particularly common after
pneumococcal meningitis, where as many as 30% of patients
suffer from hearing loss [3]. Some studies have found lower
incidences (7–12%) of post-meningitis hearing loss in chil-
dren compared to adults [5,6], whereas others have reported
similar incidences [7]. Animal research has shown a correl-
ation between pneumococcal concentration in the middle
ear and the development of hearing loss [8], indicating that
early diagnosis of concurrent AOM and subsequent myrin-
gotomy could be beneficial. Swedish meningitis guidelines
include a recommendation to perform otoscopy in all
patients with meningitis, and to follow up patients with
audiometry [9].
hearing loss in patients treated for bacterial meningitis in
the Swedish county of Skåne (1.4 million inhabitants),
between 2000 and 2017 and to investigate risk factors for
hearing loss.
Materials and methods
In this retrospective, observational study, medical records
from all patients admitted to hospitals in Skåne county with
the ICD-code G00 (bacterial meningitis) between 2000 and
2017 were retrieved. Exclusion criteria were neonatal, viral,
fungal or non-infectious meningitis, borrelia or nosocomial,
postoperative or ventricular shunt-related infections.
Information about gender, age, otoscopy results, CT/MRI
signs of middle ear infection, microbiological results, sub-
jective hearing loss and hearing tests were extracted from
medical charts. Where pure tone audiograms were available,
pure tone averages (PTA4; defined as the average of hearing
thresholds at 500, 1000, 2000 and 4000 Hz) were extracted,
as was the presence of conductive hearing loss (defined as
an air-bone gap of
10 dB on at least two adjacent frequen-
cies). Hearing loss was defined as PTA4
25 on either ear,
and further subdivided into mild (25–40 dB HL), moderate
(41–70 dB HL) and severe (>70 dB HL). High frequency

CONTACT Marie Gisselsson-Solen marie.gisselsson-solen@med.lu.se Department of Otorhinolaryngology, Head and Neck Surgery, Skåne University
Hospital, Lund 22185, Sweden
ß 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/),
which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.
 ACTA OTO-LARYNGOLOGICA 299

No of patients with severe

average2
Initial number of

hearing loss, left ear

HF

0
0
17
17
34
patients n=556

No meningitis n=65
Medical chart

PTA41
1
0
5
5
11
unavailable n=1

average2
Patients with

moderate hearing loss,

No of patients with

HF
meningitis n=490

0
0
13
12
25
left ear
Viral infection n=116
Non-infectious n=2

PTA41
0
0
11
14
25
Fungal infection n=3

average2
No of patients with mild
Patients with bacterial

hearing loss, left ear

HF

0
0
17
3
20
meningitis=369
Deceased n=24
Follow-up elsewhere n=12
Neonatal Group B
streptococcus infection n=9

PTA41
Borrelia burgdorferi n=83

0
0
14
8
22
Postoperative infection n=46
Shunt infections n=8
No of patients with severe

average2
Total number of hearing loss, right ear
included patients
HF

0
0
12
18
30
n=187

Figure 1. Patient flow chart.

hearing was evaluated by calculating the average hearing
PTA41
0
0
4
4
8
thresholds at 6000 and 8000 Hz.
By including data over 18 years in one of the most popu-
lous counties in Sweden, we hoped to be able to estimate
average2
moderate hearing loss,

the incidence of bacterial meningitis in Sweden over a long

No of patients with

HF

0
0
20
10
30

period of time. The proportion of otogenic meningitis cases,

right ear

time trends, microbiology and outcomes other than hearing

HF average ¼ High frequency average ¼ average hearing thresholds on 6000 and 8000 Hz.

loss will be reported separately.

Table 1. Age distribution and occurrence of hearing loss in the respective age groups.

PTA41

The study was approved by the Ethics Review Authority.

0
0
12
12
24

The STROBE guideline was used for the preparation of

the manuscript.
average2
No of patients with mild
hearing loss, right ear
HF

0
0
12
3
15

Statistical analyses
Data were analysed using Stata 16.1 (College Station, TX,
PTA4 ¼ Pure tone average on 500, 1000, 2000 and 4000 Hz.

USA). The association between sensorineural hearing loss and

PTA41
0
0
15
11
26

possible risk factors were investigated using uni- and multivari-

ate logistic regression. Variables showing a substantial associ-
ation with the outcome in the univariate analysis were kept in
No of patients

loss (% of age
with hearing

group total)

the multivariate analysis. Patients were divided into four age

2 (10)
1 (5)
47 (53)
31 (53)
81 (43)

groups; children (0–11 years), teenagers (12–21 years), adults of

working age (22–65 years), and elderly (over 65 years).
In a substantial number of patients (n ¼ 68), hearing tests
patients (%)

were not performed. In order not to overestimate the preva-

187
20 (11)
19 (10)
89 (48)
58 (31)
No of

lence of hearing loss, calculations were done in two ways:

The first was by including only those who had done some
sort of hearing test (analysis A), and the other by including
Age (years)

all patients, making the conservative assumption that those

who had not done a hearing test did not have a hearing loss
12–21
22–65

Total
0–11

>65

(analysis B). As the focus of the study was to investigate

1
2
300 F. PERSSON ET AL.
Table 2. Bacteriological findings.
Bacterium Patients (%)
S. pneumoniae 108 (58)
N. meningitidis 23 (12)
S. pyogenes 6 (3)
S. aureus 7 (4)
Listeria monocytogenes 5 (3)
H. influenza type B 8 (4)
Group B streptococci 3 (2)
Other 8 (4)
No growth 19 (10)
sensorineural hearing loss after bacterial meningitis, patients
with a purely conductive hearing loss were not included in
the hearing loss group.
Results
Initially, 556 patients were identified. After applying exclu-
sion criteria, 187 patients remained (Figure 1), 106 of whom
were men. The age distribution is shown in Table 1.
Hearing tests were available in 119 cases, 107 of which were
pure tone audiometries. Hearing loss was diagnosed in 81
patients, in 13 cases unilaterally, and was more common in
adults and elderly (Table 1). Three patients had bilateral
severe hearing loss, and an additional 13 had unilateral
severe hearing loss. Of the 105 patients where data for 6
and 8 kHz were available, hearing thresholds >40 dB on
these frequencies occurred frequently in adult patients, how-
ever, never in children or teenagers (Table1). The most
commonly identified bacteria were S. pneumoniae (58%)
and N. meningitidis (12%; Table 2).
In the univariate analysis, there was no evidence of a cor-
relation between gender and hearing loss, however, there
was strong evidence of adult and elderly patients having
greatly increased odds of hearing loss (OR 11, p ¼ .003 and
OR 26, p < .001 in analysis A and OR ¼ 7.3, p ¼ .01 and
OR ¼ 8.4, p ¼ .007 in analysis B).
The univariate analysis also supplied evidence that
patients with pneumococcal infection had increased odds of
hearing loss (OR ¼ 2.3, p ¼ .046 and OR ¼ 4.1, p < .001 for
analysis A and B, respectively). On the other hand, patients
with meningococcal infections had decreased odds of hear-
ing loss (OR ¼ 0.2, p ¼ .01 in analysis A and OR ¼ 0.2,
p ¼ .009 in analysis B). There was also evidence for an asso-
ciation between hearing loss and concurrent AOM (OR ¼
1.4, p ¼ .4 and OR ¼ 3.3, p < .001 for analysis A and B,
respectively).
Age, concurrent AOM and the presence of S. pneumo-
niae/N. meningitidis was kept in the multivariate analysis
(Table 3). There was still strong evidence that age was a risk
factor for hearing loss. In analysis A, there was no evidence
of an association between AOM or pneumococcal infection
and hearing loss, however, in analysis B, patients with con-
current AOM had twice the odds of hearing loss (OR ¼ 2.1,
p ¼ .04), and for those with pneumococcal infection, the
odds increased 3.6-fold (p ¼ .001). In the multivariate ana-
lysis, no association was seen between meningococcal infec-
tion and hearing loss.
Table 3. Correlation between risk factors and the development of sensori-
neural hearing loss after bacterial meningitis.
All patients (n ¼ 187) Patients with hearing tests (n ¼ 119)
Odds ratio 95% CI p Odds ratio 95% CI p
0–11 years ref – – ref – –
12–21 years 0.7 0.05–9.9 .8 0.7 0.05–9.9 .8
22–65 years 13.0 2.5–68.0 .002 8.0 1.7–38.4 .009
65þ years 28.0 4.7–164.7 <.001 9.8 2.0–47.9 .005
AOM 0.7 0.3–1.7 .4 2.1 1.04–4.4 .040
S. pneumoniae 1.5 0.5–1.7 .4 3.6 1.7–7.8 .001
N. meningitidis 0.7 0.09–5.08 .7 1.8 0.4–8.9 .5
Multivariate logistic regression with adjustments for age group, AOM and
pneumococcal/meningococcal infection.
Discussion
In this retrospective study, which comprised data from an
entire Swedish county during 18 years, the strongest pre-
dictor for post-meningitis hearing loss was age. There was
also evidence (analysis B) that pneumococcal infection and
concurrent AOM increased the odds of hearing loss. Despite
recommendations in the national guidelines, more than a
third of patients had not done a hearing test after recovery.
The main outcome in this study was post-meningitis hear-
ing loss. Regrettably, 1/3 of patients had not done a hearing
test after recovery. In order not to over-estimate the preva-
lence of hearing loss, we decided to analyse the data, not
only with patients lacking hearing tests censored, but also by
using all the patients, assuming that those who had not done
a hearing test did not suffer from any new hearing loss.
There are several reasons why this is a reasonable assumption
to make: First of all, since the Swedish meningitis guidelines
pay attention to hearing loss as a common sequela to menin-
gitis, most patients were probably asked about subjective
hearing loss before being released from hospital, and there is
no reason to believe that anyone complaining of hearing loss
would be denied a hearing test. Secondly, in Skåne county,
Sweden, where this study was performed, anyone can easily
schedule a hearing test if they suspect that their hearing has
deteriorated. Lastly, children are regularly followed up with
audiometries via child health centres and school health care.
All in all, it is therefore reasonable to believe that no signifi-
cant hearing loss should go undetected.
Of those who underwent a hearing test, 68% had a hear-
ing loss, and the corresponding figure for the entire cohort
was 43%. Both these prevalences exceed the 30% which has
been described previously [3]. This might, in part, be
explained by different definitions of hearing loss, and by
some patients in the present study having had previously
undiagnosed hearing loss. The extremely high prevalence of
68% hearing loss among the patients who had done an audi-
ometry indicate that it was reasonable to analyse the data in
two ways. The conservative assumption that patients lacking
audiometries had normal hearing should at least not lead to
an over-estimation of the prevalence of hearing loss.
A consistent finding in this study was that age increased
the risk of developing hearing loss. Age >70 years has previ-
ously been associated with an ‘unfavourable outcome’ [10],
Since most patients in this study had not tested their hear-
ing prior to their meningitis, the finding might, at least

partly, be explained by the fact that the prevalence of hearing
loss increases with age. Some patients might therefore have
had previously undiagnosed presbyacusis, an assumption fur-
ther supported by the large number of patients with high fre-
quency hearing loss in the two older age groups. Undiagnosed
presbyacusis should also have been present in some patients
with missing hearing tests, where we assumed normal hearing,
which should somewhat counteract any such overestimation
and might explain why the effect sizes were not as great in
analysis B as in analysis A. Missing audiometries were not less
common among the older age group (data not shown).
There was a correlation between AOM and hearing loss in
analysis B, however, not in analysis A, presumably due to the
larger sample size in analysis B. The association seen in ana-
lysis B seems to have been partly confounded by pneumococcal
infection, since the effect estimate decreased in the multivariate
analysis, however, the odds of hearing loss was still twice as
high among patients with AOM in the multivariate analysis. A
Dutch study also found that the odds of hearing loss increased
by 2.6 in patients with concurrent AOM [11].
Streptococcus pneumoniae – a common otopathogen –
increased the odds of hearing loss almost four-fold in ana-
lysis B after controlling for other risk factors. Analogous to
the findings for AOM, this was not seen in analysis A,
again, probably due to the smaller sample size in that ana-
lysis. That patients with pneumococcal meningitis are more
likely to develop long-term hearing loss has been noticed in
a previous meta-analysis as well as in a retrospective review
on children [3,12]. The negative association between menin-
gococcal infection and hearing loss in the univariate analysis
was not present in the multivariate analysis, indicating that
the former results were confounded by age; meningococcal
infections being almost exclusively found among children
and teenagers (data not shown).
This study has several limitations, the greatest of which is
the retrospective design, meaning that many patients did
not undergo hearing tests. The assumption that patients
lacking hearing tests did not suffer from post-meningitis
hearing loss (analysis B) seems reasonable to make, as it is
unlikely that a patient complaining about a recent hearing
loss should not be referred for an audiometry. The one
group where this would be more likely to occur is young
children, however, the association between age and hearing
loss was even more pronounced in analysis A, where only
those who had actually done a hearing test were included.
In addition, most patients had not done hearing tests before
their meningitis, so there was no way of knowing for certain
that the hearing loss was caused by the meningitis. The
design also means that microbiological PCR tests and sero-
typing were not performed.
A strength of the study is that it encompasses a whole
county of Sweden during a period of 18 years, implying that
the results should be generalisable.
Better knowledge of risk factors for post-meningitis hear-
ing loss can hopefully result in better compliance with exist-
ing guidelines, leading to more patients undergoing
otoscopy when admitted to hospital with bacterial
ACTA OTO-LARYNGOLOGICA 301
meningitis, and more patients being followed up audiologi-
cally after recovery. As discussed above, early diagnosis of
concurrent AOM, and subsequent myringotomy might
decrease the risk of developing hearing loss.
Conclusion
This study showed that the incidence of hearing loss after bac-
terial meningitis was strongly associated with age, but also
with concurrent acute otitis media and S. pneumoniae infec-
tion. In an on-going prospective study on the same population,
we hope to be able to confirm the findings more robustly.
Disclosure statement
No potential conflict of interest was reported by the authors.
ORCID
Marie Gisselsson-Solen http://orcid.org/0000-0003-2802-2343
References
[1] van de Beek D, de Gans J, Spanjaard L, et al. Clinical features
and prognostic factors in adults with bacterial meningitis. N
Engl J Med. 2004;351(18):1849–1859.
[2] Bargui F, D’Agostino I, Mariani-Kurkdjian P, et al. Factors
influencing neurological outcome of children with bacterial
meningitis at the emergency department. Eur J Pediatr. 2012;
171(9):1365–1371.
[3] Edmond K, Clark A, Korczak VS, et al. Global and regional risk
of disabling sequelae from bacterial meningitis: a systematic
review and meta-analysis. Lancet Infect Dis. 2010;10(5):317–328.
[4] Svendsen MB, Ring Kofoed I, Nielsen H, et al. Neurological
sequelae remain frequent after bacterial meningitis in children.
Acta Paediatr. 2020;109(2):361–367.
[5] Chandran A, Herbert H, Misurski D, et al. Long-term sequelae
of childhood bacterial meningitis: an underappreciated prob-
lem. Pediatr Infect Dis J. 2011;30(1):3–6.
[6] Richardson MP, Reid A, Tarlow MJ, et al. Hearing loss during
bacterial meningitis. Arch Dis Child. 1997;76(2):134–138.
[7] Kutz JW, Simon LM, Chennupati SK, et al. Clinical predictors
for hearing loss in children with bacterial meningitis. Arch
Otolaryngol Head Neck Surg. 2006;132(9):941–945.
[8] Perny M, Roccio M, Grandgirard D, et al. The severity of infec-
tion determines the localization of damage and extent of sen-
sorineural hearing loss in experimental pneumococcal
meningitis. J Neurosci. 2016;36(29):7740–7749.
[9] Svenska Infektionsl€akarf€ oreningen. Vårdprogram Bakteriella
CNS-infektioner. 2020. Available from: https://infektion.net/var-
dprogram/cns-infektioner-bakteriella/#.
[10] Tubiana S, Varon E, Biron C, et al. Community-acquired bacter-
ial meningitis in adults: in-hospital prognosis, long-term disabil-
ity and determinants of outcome in a multicentre prospective
cohort. Clin Microbiol Infect. 2020;26(9):1192–1200.
[11] Heckenberg SG, Brouwer MC, van der Ende A, et al. Hearing
loss in adults surviving pneumococcal meningitis is associated
with otitis and pneumococcal serotype. Clin Microbiol Infect.
2012;18(9):849–855.
[12] Woolley AL, Kirk KA, Neumann AM, Jr, et al. Risk factors for
hearing loss from meningitis in children: the children’s hospital
experience. Arch Otolaryngol Head Neck Surg. 1999;125(5):
509–514.